Failure to Complete Post-Fall and Neurological Assessments and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that post-fall assessments, including neurological assessments, were completed for residents who experienced unwitnessed falls. Specifically, two residents with histories of falls did not receive neurological assessments after their unwitnessed falls, despite facility protocol requiring such assessments. Additionally, post-fall assessments were not completed for certain incidents. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that these assessments were not performed as required. Review of facility policies revealed a lack of clear guidance regarding neurological assessments after unwitnessed falls, and documentation did not support that follow-up was conducted as outlined in the fall reduction policy. The facility also failed to implement and document fall prevention interventions for a resident at risk for falls. This resident, with diagnoses including Alzheimer's disease and dementia, experienced multiple falls where prescribed interventions such as non-skid socks and use of a walker were not in place at the time of the incidents. Documentation did not confirm whether the resident was compliant with these interventions, and new interventions were added after each fall without evidence of consistent implementation. These failures were identified through observation, staff interviews, record review, and policy review.